Management of Aortic Dissection

Initial Assessment and Stabilization

The European Society of Cardiology recommends transferring the patient to an intensive care unit for appropriate monitoring with invasive blood pressure monitoring via arterial line, and providing adequate pain control with morphine sulfate to reduce sympathetic stimulation 3
Diagnostic imaging should be obtained immediately, using CT angiography, transesophageal echocardiography (TEE), or MRI, depending on institutional capabilities and patient stability 4
For profoundly unstable patients, bedside transthoracic echocardiography (TTE) should be performed to identify cardiac tamponade or other immediate life-threatening complications 3, 5

The European Heart Society recommends targeting systolic blood pressure between 100-120 mmHg and heart rate ≤60 beats per minute to reduce shear stress on the aortic wall 3
Intravenous beta-blockers should be administered as first-line therapy, with options including propranolol, esmolol, and labetalol 3, 2
If beta-blockers alone are insufficient for blood pressure control, vasodilators such as sodium nitroprusside should be added, but never used without prior beta-blockade 3, 6

The American Heart Association recommends immediate surgical consultation and emergency surgical repair for Type A dissection, with surgical options including resection of all aneurysmal aorta and proximal extent of dissection, aortic valve resuspension, and aortic root replacement 1, 5
For Type B dissection, uncomplicated cases should be managed medically with aggressive blood pressure and heart rate control, while complicated cases may require intervention, such as TEVAR 1, 2

For patients with hypotension, volume administration should be considered, and vasopressors should be avoided if possible, as they may cause further false lumen propagation 1, 5
Patients with hereditary diseases, such as Marfan syndrome, should receive lifelong beta-blocker therapy 2
Pregnant patients require management by a multidisciplinary team at specialized centers 2

The American College of Cardiology recommends transitioning from intravenous to oral beta-blockers after 24 hours of hemodynamic stability, and targeting long-term blood pressure <135/80 mmHg 6
Regular imaging follow-up is necessary to monitor for complications, such as false lumen expansion or aneurysm formation 2, 6